Provider Demographics
NPI:1508113457
Name:KOMRO, KATIE M (NP-C)
Entity Type:Individual
Prefix:
First Name:KATIE
Middle Name:M
Last Name:KOMRO
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:
Other - First Name:KATIE
Other - Middle Name:M
Other - Last Name:HOLDEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:NP
Mailing Address - Street 1:1200 OAKLEAF WAY
Mailing Address - Street 2:SUITE A
Mailing Address - City:ALTOONA
Mailing Address - State:WI
Mailing Address - Zip Code:54720-2245
Mailing Address - Country:US
Mailing Address - Phone:715-832-1400
Mailing Address - Fax:715-832-4187
Practice Address - Street 1:1200 OAKLEAF WAY
Practice Address - Street 2:SUITE A
Practice Address - City:ALTOONA
Practice Address - State:WI
Practice Address - Zip Code:54720-2245
Practice Address - Country:US
Practice Address - Phone:715-832-1400
Practice Address - Fax:715-832-4187
Is Sole Proprietor?:No
Enumeration Date:2012-08-09
Last Update Date:2021-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI5017-33363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1508113457Medicaid
WIK400132063Medicare PIN